Notice Of Harassment / Discrimination Complaint Form printable pdf download

Notice Of Harassment / Discrimination Complaint Form

Notice of Harassment/Discrimination Complaint

Directions: If you believe that you have been unlawfully harassed/

discriminated against, please fill out this form and return it to the Human

Resource Office. If more space is necessary, please continue your

comments on the back of this form.

Name:_________________________________ Date of Complaint:__/__/__

Department:____________________ Job Title:______________________

Interviewed by:___________________________

Basis of Discrimination:

__Sex(Gender) __Race __Color __Retaliation __Age __Religion

__Creed __National Origin __Disability __Sexual Orientation

__Marital or Veteran Status

or any other legally protected classification.

Individual(s) who allegedly committed harassment/discrimination:

a.)_____________________________________

b.)_____________________________________

c.)_____________________________________

Describe the nature of your complaint. Include dates and as much

detail as possible.

Why do you believe this action was taken against you?

Identify all employees/students/or others with knowledge of the

conduct about which you are complaining:

Notice Of Harassment / Discrimination Complaint Form